Answer Sigmoid volvulus

This is a rotation of the gut about its own mesenteric axis, which produces complete intestinal obstruction. It is most commonly seen in the elderly or those with psychiatric disorders taking medication. Venous congestion leading to infarction can occur. On the plain abdominal film a hugely dilated loop of bowel is seen extending from the pelvis. The inverted 'U' loop is commonly devoid of haustra and is seen to extend as far as the liver in the right upper quadrant, and to the 10th thoracic vertebra 90 superiorly. The inferior convergance of the two limbs of the loop is often left sided. There may be some secondary loops of dilated large bowel associated with these appearances. Sigmoidoscopy can be both diagnostic and therapeutic by releasing flatus. Approximately half of patients have a further episode of volvulus within 2 years. In caecal volvulus, the caecum is seen to revolve around its axis to lie across the midline in the upper/central abdomen Fig. 2.12.

Large bowel obstruction gives rise to distention of the large bowel down to the level of obstruction sometimes with accompanying small bowel dilation. The commonest cause is colonic carcinoma. Other causes include volvulus, intussusception or extrinsic compression.

In paralytic ileus both the large and small bowel can become dilated which can extend down into the sigmoid colon and rectum (see Fig. 2.13). Differentiation from low large bowel obstruction may be difficult.

Fig. 2.12 Caecal volvulus.

Fig. 2.13 Pseudo-obstruction. This can be difficult to distinguish from distal large bowel obstruction. Large and small bowel distension is usually present with reduced small bowel distension on serial films. If concern persists an instant enema can be performed.

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